addressing the surgery and diagnostic backlog: a path to

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Surgery & Diagnostic Recovery Report

Addressing the Surgery and Diagnostic Backlog:A Path to Recovery

June 17, 2021

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The health system’s pandemic response has resulted in

multiple slow downs of surgical and diagnostic procedures.

We estimate the backlog is over 110,000 surgical and

diagnostic procedures, and growing:

• Over 39,000 surgical procedures

• Over 44,000 diagnostic imaging tests

• Over 32,000 other procedures, including endoscopies,

allergy testing and mammograms

While some progress was made in February and March, the

backlog is growing again because of the third wave.

The backlog is having a significant impact on patients who are

waiting longer. For patients, this has meant:

• Pain and discomfort with longer waits

• Minor health concerns turning into larger issues that require

more complex procedures and treatment

• Patient harm (delayed diagnosis, disability or death)

The surgical slow downs have not only affected quality of life

procedures, such as cataract surgeries and hip replacements,

but cardiac and cancer surgeries have also been affected.

Doctors Manitoba applauds the government’s investments to

help address the backlog, including $2.5 million in contracts

and $50 million announced in Budget 2021. This is a strong

start, but a more comprehensive and accountable plan is

needed to reassure Manitobans about when and how the

backlog will be fully addressed.

Recommendations

1. A provincial commitment is needed to fully address the

pandemic backlog by a fixed date, including ensuring

all the necessary funding is available.

(example, by Dec. 31, 2022)

2. Create a Surgery and Diagnostic Recovery Task Force

to lead the immediate and sustained task of

addressing the backlog. The Task Force should

include health system leaders as well as frontline

physicians, nurses, technologists and others to

collaboratively address barriers, such as the nursing

shortage, and consider models of care that support an

expedited and safe recovery.

3. Provide monthly public reports on progress, including

the size of the backlog, a breakdown by procedure,

and details on plans and actions to address the issue.

Summary: Surgery & Diagnostic Recovery Plan

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Research & Methods

This report relies on extensive research:

→ Doctors Manitoba survey of physicians

Conducted April 1 to 11, 20211,022 responses, including 238 surgeons, radiologists and anesthetists.

→ Probe Research survey of Manitoba adults

Conducted April 5 to 14, 20211,000 responses

→ Literature Review and Jurisdictional Scan

→ Manitoba data and updates, where available

How Big is the Backlog?

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Pandemic Impact on Surgeries and Diagnostics

Like other provinces, Manitoba postponed many elective and non-urgent surgeries and diagnostic testing during the first wave, as a precaution while experts learned more about COVID-19.

Manitoba was forced to decrease surgery volumes again during the second wave. This time the move was not a precaution, but resources were needed to support a surge in COVID-19 hospital admissions and the need for more critical care capacity. Surgeries are being disrupted again to support the ICU response during the third wave.

Surgery space, such as recovery rooms, have been used for ICU patients and surgical staff have been redeployed to provide care for COVID-19 patients.

Diagnostic imaging was not as significantly affected during the second and third waves.

How big is the backlog?Estimating the backlog for surgery and diagnostics is challenging because of inconsistent and incomplete public reporting. Over the next several pages, we estimate the backlog using a variety of sources.

Nov 2, 2020

Most

Surgeries

Postponed

Jan 11, 2021

Some

Surgeries

Resume

Mar 23, 2020

Most

Surgeries

Postponed

Apr 24, 2020

Some

Surgeries

Resume

Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb MarJan Feb Apr May

May 8, 2021

Most

Surgeries

Postponed

2020 2021

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Estimating the Pandemic Surgery BacklogTo estimate the full size of the surgery backlog generated

during the pandemic, we considered several factors:

• Shared Health’s public statement that the backlog from

the first and second waves had reached 16,000 cases.

• CIHI’s comprehensive reporting on surgery volumes

changes during just the first wave of COVID-19, which

found a 35% decrease in surgical volumes (12,011

cases) in Manitoba.

• Manitoba Health’s monthly public reporting of cataract,

hip/knee and cardiac procedure volumes (down 32%).

• Surgeons’ estimates of a 40% decrease in surgery

volumes, and their estimate of their growing wait list.

(estimated at 35,000 – 45,000 elective procedures).

• Physicians’ estimates that they have decreased

referrals for surgery by 11% during pandemic. This is a

potential “hidden” backlog not captured elsewhere,

which we have incorporated into our estimate.

Pandemic backlog estimate covers March 2020 to May 2021.

Estimated Surgery Backlog:

and counting

39,000CASES

https://www.cihi.ca/en/covid-19-resources/impact-of-covid-19-on-canadas-health-care-systems/covid-19s-effect-on-hospital

https://www.gov.mb.ca/health/waittime/

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Wave 1

Surgery Backlog for Cataract, Hip/Knee & Cardiac

% change in surgery volume compared to same month from pre-pandemic period 2019/2020

Source: Manitoba Health

Cataract Surgery

Volume: 19%

Backlog: 3,273

Hip/Knee Surgery

Volume: 56%

Backlog: 6,001

Cardiac Surgery

Volume: 13%

Backlog: 163

Wave 2

Cataract, hip/knee and cardiac procedures are reported publicly, so they offer a view into how surgeries have been

impacted by the slow downs. Surgical volumes decreased the most during the first and second waves, but they also

never fully recovered between waves. COVID-19 precautions add additional time to each procedure, which means a

return to 100% of “normal” OR time does not result in 100% of “normal” surgery volumes.

Cataract

Hip/Knee

Cardiac

-120%

-100%

-80%

-60%

-40%

-20%

0%

20%

40%

60%

80%

Cardiac Cataract Hip/Knee

Wave 3

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55%

50%

50%

45%

42%

42%

39%

38%

30%

19%

17%

0% 10% 20% 30% 40% 50% 60%

Obstetrics and Gynaecology

Cardiovascular Surgery

ENT (Head and Neck)

Plastic Surgery

Neurosurgery

Vascular Surgery

Orthopaedic Surgery

Thoracic Surgery

General Surgery

Ophthalmology

Urology

Change in surgery volumes during pandemic

Surgeons estimate their

surgical volumes are

down 40% overall

40%

Reported Decrease in Surgical Volumes

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Estimating the Diagnostic Pandemic Backlog

The diagnostic imaging backlog is much easier to

calculate as volumes are reported publicly on a

monthly basis by Manitoba Health.

The decrease in volume during the pandemic includes:

• 5,472 CT Scans

• 23,484 Ultrasounds

• 14,234 MRI Scans

• 1,116 Myocardial Perfusion Studies

(heart stress tests)

Pandemic backlog estimate covers March 2020 to April 2021.

Estimated Diagnostic

Testing Backlog:

44,300CASES

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Wave 3Wave 1 Wave 2

Diagnostic Volume Changes

% change in diagnostic imaging volume compared to same month from pre-pandemic period 2019/2020

Source: Manitoba Health

CT Scans

2% (5,472 scans)

Ultrasound

10% (23,484 scans)

Myocardial Perfusion

17% (1,116 studies)

Diagnostic volumes dropped significantly during the first wave, but they recovered more over the summer than

surgery and they were less impacted by the second wave. There is still an enduring net loss in diagnostic volumes

during the pandemic, however, and it is unclear how the third wave will impact on efforts to catch up.

MRI

13% (14,234 scans)

-80%

-70%

-60%

-50%

-40%

-30%

-20%

-10%

0%

10%

20%

30%

MRI CT Myocardiac Perfusion Studies Ultrasound

CT

UltrasoundMyocardial Perf.

MRI

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Pandemic Backlog for Other Procedures

There are several other diagnostics that have been

impacted. The following estimates were developed

based on issues identified by physicians.

The pandemic backlog based on decreased volumes

and wait list analysis includes:

• 1,889 Allergy Tests

• 10,200 Endoscopies

• 20,502 Mammograms

Pandemic backlog estimate covers March 2020 to March 2021

for allergy tests and mammograms. For endoscopies, it covers

March 2020 to May 2021.

Estimated Backlog for

Other Diagnostics

32,591CASES

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-100%

-80%

-60%

-40%

-20%

0%

20%

40%

Allergy Testing Diagnostic Endoscopy Mammography

Wave 1

Other Procedures Volume Changes

% change in diagnostic volumes compared to same month from pre-pandemic period 2019/2020

Source: Doctors Manitoba review of physician claims data

Diagnostic

Endoscopies

20% (7,200 scopes)

Mammograms

19% (20,502 scans)

Allergy Tests

13% (1,889 tests)

Wave 2

Other diagnostics, including mammograms, diagnostic endoscopies and allergy tests, saw sharp decreases in

volume during the first wave, with some recovery over the summer and smaller decreases during the second wave.

Endoscopies

Allergy tests

Mammograms

Impact of Backlog

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243%

204%

177%

173%

158%

101%

97%

87%

86%

64%

54%

42%

0% 50% 100% 150% 200% 250% 300%

Neurosurgery

Cardiovascular Surgery

General Surgery

Vascular Surgery

Orthopaedic Surgery

Thoracic Surgery

ENT (Head & Neck)

Obstetrics and Gynaecology

Family Practice - Rural

Plastic Surgery

Ophthalmology

Urology

Reported Change in Wait List

Surgery Wait Lists More Than Double

Surgeons estimate their

wait lists have more than

doubled during the

pandemic, up 108%.

WAIT LIST108%

Estimate is based on survey of surgeons conducted in April 2021

Cardiac and

Neurosurgery wait

lists have more

than tripled

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Impact on PatientsPhysicians described a wide range of impacts the

backlog and growing wait is having on their

patients. This includes:

→ Prolonged pain and discomfort with longer

waits

→ Minor health concerns turning into larger

issues that require more complex procedures

and treatment

→ Patient harm (delayed diagnosis, disability or

death)

→ Negative impacts on:

• Quality of life

• Physical health (decreased mobility)

• Mental health (stress, anxiety, depression

and suicidal ideation)

“My patients live with debilitating pain. Everyday month that their surgery is delayed, is another month longer they have to suffer, avoid activity, and be non-productive in society.”(Orthopedic Surgeon)

“I currently spend more time talking to patients about wait times then I do actually caring for them.” (Surgeon)

“My patients are going blind, losing the ability to live independently, enjoy activities, drive and take their medications safely. ” (Ophthalmologist)

“The uncertainty and frequent cancellations are causing anxiety. Patients are depressed not knowing when their wait will be over.” (Family Physician)

“Patients are experiencing decreasing mobility with impacts on health and major decrease in quality of life. Some are turning to narcotics.” (Surgeon)

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Concerning ImpactsWhen most surgeries were paused due to the pandemic,

provincial officials have repeatedly stressed that only

non-urgent and elective procedures would be affected.

However, some physicians have reported concerning

cancellations and delays for cardiac and cancer

surgeries.

For cardiac patients, physicians have identified

significant deterioration among patients waiting for heart

surgery, including at least two patient deaths on the wait

list.

For cancer patients, physicians provided many examples

of delayed biopsies and surgeries, resulting in cancers

advancing in stage, spreading, and requiring additional

treatments.

CIHI’s analysis of surgical impacts from the first wave

found a 16% decrease in cardiac surgeries and a 9%

decrease in cancer surgeries.

“My patient has endometrial cancer and her surgery was delayed. She started on chemotherapy which should not have been the case. Patient very distraught and depressed for fear of cancer spread. ” (Family Physician)

“We have had deaths on the waitlist and an alarming number of patients over waitlist benchmarks with symptomatic deterioration .” (Cardiac Surgeon)

“Patients are waiting longer for bladder cancer surveillance and surgery. ” (Urologist)

“Some patient cancers are not confirmed and operated on in time.” (Family Physician)

“We have seen a stage shift where cancers have progressed. That leads to having to treat more patients with radiotherapy or chemo.” (Family Physician)

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Impact on ChildrenWe estimate the surgery backlog for children and youth

to be 3,500 to 5,000 cases.

Pediatric specialists have reported extended delays for many

procedures, with many children waiting well-beyond the

recommended wait times.

For some children, the delays lead to more complex surgeries

which, in turn, require much longer hospital stays for recovery. In

some cases, this has led to cancer advancing and spreading.

While most children’s hospitals across Canada were able to

address their backlogs by increasing their capacity above 100%,

Manitoba’s Children’s Hospital hasn’t been able to get above 60-

80% of normal capacity due to ongoing nursing shortages.

Prioritizing surgeries will be a critical part of recovery, and an

emerging framework from Pediatric Surgical Chiefs of Canada can

be used to help guide the process.

https://www.waittimealliance.ca/wp-content/uploads/2014/05/Paediatric_SurgeryP-CATS_List.pdf

https://www.cmaj.ca/content/192/41/E1212

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Impact on Women’s HealthPhysicians raised serious concerns about the impact on Women’s

Health. For example:

• Obstetrician/gynecologists estimate a 55% decrease to their

surgical volumes during the pandemic.

• Many surgical procedures have been postponed, including a

40%-70% drop in uro-gynecology surgeries and a 24% drop in

hysterectomies.

• Surgeries for pregnancy loss or fetal demise have been delayed,

as has surgical abortion.

• Women have experienced delays in diagnosing and treating

cancers, leading to spread and more difficult treatments. In

some cases, surgery was no longer a treatment option.

• There have been 20,000 fewer mammograms during the

pandemic.

Surgical slow downs at Women’s Hospital have been extensive.

This is also the case at St. Boniface, which became the centre for

uro-gynecology after hospital consolidation, leaving women

languishing with pain and incontinence issues.

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Manitobans are concerned, too.

81% of Manitobans are

concerned the pandemic

might delay a medical test

or surgery if they need

one.

Manitobans are feeling the impact of the

disruptions, with 12% reporting they had a

diagnostic test cancelled and 6% reporting a

surgery cancellation.

Incidence of cancellations among Manitobans

Source: Probe Research Survey

Addressing theBacklog

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Barriers to Addressing Surgery Backlog

While the provincial government has pledged $50

million to address the backlog in surgeries, the barriers

to addressing it require thorough planning and

collaboration.

In addition to sufficient funding, the barriers to

addressing the backlog include insufficient nursing

resources and a lack of OR time and recovery space.

These issues were identified before the third wave

arrived in Manitoba, and they have only been

exacerbated as recovery space and surgery nurses

were redirected to support expanded critical care

capacity.

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Physician Capacity to Help with Recovery

97% of surgeons surveyed are

able to pick up additional

slates to help address the

backlog.

On average, surgeons indicated

they have capacity to pick up 4 to 5

slates each per month.

100% of anesthesiologists surveyed

are able to pick up additional

slates as well.

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Flexibility for Additional Slates

Surgeons would prefer to pick up additional

slates during weekdays and during

traditional slowdown periods, preferred by

86% and 66% respectively.

87% are willing to work at other hospitals

within their primary health region, and 74%

would pick up additional slates in private

surgical facilities if needed.

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While diagnostic tests and procedures saw significant volume decreases during the first

wave, they recovered more than surgery over the summer, and they have been less

impacted by the second and third waves.

Radiologists identified three significant barriers to addressing the backlog for diagnostic

imaging:

• 83% identified insufficient technologists.

• 88% agree that additional equipment will be needed, and/or there may be opportunities to

expand operating hours for some existing equipment.

Radiologists are willing to increase their workload to address the backlog.

Addressing the Diagnostic Backlog

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What is Needed?

All provinces had to suspend surgeries and

diagnostics due to the pandemic. However,

the plans to address the resulting backlogs

vary greatly by province.

In BC, for example, a comprehensive

surgery renewal plan was launched in May

2020. The plan was upfront, noting it could

take 17-24 months to address the backlog.

Regular public progress reports followed,

and in March 2021, the province reported

that 95% of the backlog in cases had

already been completed.

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Doctors are ready. They are willing to work more to address the backlog in surgery and diagnostic procedures, and they’re ready now.

Manitoba is now in its third wave of COVID-19, and surgical

services are now facing their third disruption. The backlog for

surgery and diagnostics is over 110,000 cases and catching up is

a mammoth task.

Doctors Manitoba offers the following recommendations to help

chart a constructive path for surgical and diagnostic recovery:

1. Commit to fully addressing the pandemic backlog by a

fixed date (e.g. Dec 31, 2022), including ensuring all the

necessary funding and resources are available.

The government has committed funding to start addressing

the backlog, though more may be needed. The next step is to

get specific, with a commitment to fully address the backlog

by a specified date. The date and required funding should be

decided following further planning by health system leaders.

2. Create a Surgery and Diagnostic Recovery Task Force to

lead the immediate and sustained task of addressing the

backlog. The Task Force should include health system

leaders and frontline physicians, nurses, technologists

and others to work collaboratively on this priority.

The backlog is massive. It will require strong leadership and

collaboration to ensure this issue becomes a top priority. It

will require addressing the nursing shortage and revisiting

models of care. Health system leaders must work with those

on the front line to identify and address the barriers together.

3. Provide monthly public reports on progress, including

the size of the backlog, a breakdown by procedure, and

details on plans and actions to address the issue.

Accountability and transparency are essential for a plan to

have credibility with the thousands of patients waiting for a

surgery or diagnostic test.

Addressing the Backlog

addressing the surgery and diagnostic backlog: a path to

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